The Ebola Threat: A “new normal”?

A couple months ago while stationed in Ghana, I was approached by colleagues and friends with questions on how to prevent contagion from the deadly Ebola virus. Their concern was stoked by reports in media outlets about the rising number of confirmed cases and deaths in neighboring countries.

The alarm was justified. The current outbreak of Ebola in West Africa is the deadliest since it was first identified in 1976 in what was then Zaire (now the Democratic Republic of Congo) by Dr. Peter Piot, who later went on to lead the global fight against HIV, and others. The cumulative number of cases attributed to Ebola in Guinea, Liberia and Sierra Leone now stands at 982, including 539 deaths.

As described by Dr. Piot in his autobiography, No Time to Lose, and more recently in The Financial Times, the virus, which is assumed to circulate in bats, infects people through contact with blood or infected droplets. Once in humans, the transmission between people results from contaminated injections, contact with blood and body fluids, sex, and possibly from mother to child. About one week after infection, the patient develops severe fever, diarrhea and vomiting, starts to bleed and is affected by clots in the body’s blood vessels, which lead to generalized organ failure, shock and death. The case fatality is staggeringly high: 90% in Zaire and 60% in West Africa.

While an uncontrolled outbreak of Ebola is frightening, in principle, as advised by Dr. Piot, it should be easy to contain if health workers and health facilities adopt simple, inexpensive and effective strategies that include the use of gloves, hand-washing, safe injection practices, isolation of patients, safe and rapid removal of corpses of those killed by Ebola, tracing of contacts, and follow-up observation of at-risk populations. Social mobilization and risk communication activities that focus on “at-risk groups” (e.g., people who consume bat meat, or who frequently travel across borders) and “at-risk behaviors and actions” (e.g., preparation/consumption of “bush meat”, treating the sick, or handling corpses of infected patients), help increase knowledge about causes, symptoms and modes of prevention among the population.

We should be mindful, however, that outbreaks of Ebola and other dangerous viruses such as the Middle East Respiratory Syndrome (MERS) in Saudi Arabia, are an ever-present danger in our interconnected world. The risk of animal-to-human transmission of lurking viruses will continue to be nurtured by close contact of people with wildlife, which is facilitated nowadays by the rapid spread of human settlements, aggressive mineral extraction practices, environmental degradation, the globalization of trade and services, mobility of people across borders, and poor, inadequate, and dysfunctional health systems in many countries.

The universal health coverage agenda offers countries and the international community a “window of opportunity” to move from ad hoc, short-term responses to the development of robust public health systems and service delivery platforms. Adopting ‘One Health’ approaches is also essential—that is, collaborative efforts between public health, veterinary and environmental services. This would facilitate the sharing of information, and enable holistic analysis of risks and joint responses to prevent and control outbreaks of diseases of animal origin, such as Ebola. In doing so, countries would also be complying with WHO’s International Health Regulations that require governments to notify WHO of disease outbreaks.

As international experience shows, strong national leadership is critical to make progress in this area. And, sustained domestic funding, coupled by regional funding arrangements such as the one proposed by the Economic Community of West African States (ECOWAS) at the recent Presidential Summit to establish a Regional Pool Fund for Ebola, are necessary complements to political commitment. International support, both technical and financial, is justified as it would contribute to reduce the global risk of the spread of viruses at their source.

As recently described by Laurie Garrett of the Council of Foreign Relations, the Ebola virus in West Africa should be tackled the same way it was done in 1976: with soap, clean water, protective gear, safe medical practices, and quarantine; technology and vaccines are of no use. Also community engagement and involvement, effective contact tracing, cross-border collaboration and effective coordination would be critical. But, I would add that in pursuing a broader development agenda to end poverty and enhance shared prosperity over the medium term, countries and the international community have the responsibility to act on the recognition that environmental factors can impact human health and support the development of sustainable ‘One Health’ platforms to deal with the emergence of new viruses or the reemergence of known pathogens that risk affecting all of us across the world.

Comments

Hi Patricio, I hope you will forgive me for disagreeing with part of your piece. I agree completely that it requires a broader development agenda, one health and UHC. However,I do not agree that Ebola in West Africa should be tackled the same way as 1976. In fact, that is part of the problem is that we think the solutions lie in health and principles of outbreak management. We think we know the answers and don't listen to our communities. It requires time, trust,communication and conflict-sensitive approaches as much as soap and clean water. Many of the areas affected have had years of conflict and broken trust, many years of receiving no health care or having their fevers diagnosed as malaria. Are there sufficent numbers and trained healthworkers to differentiate an ebola fever from a malaria fever? It struck me when one Minister from an affected country pronounced that "community ignorance" was greatest threat EVD. Many of these areas are poor and have a history of civil war and conflict. When will we stop delivering our top-down approaches to communities and when will we start working with, for and through communities and place them at the centre of our efforts?

Many thanks Susan for your good comments. In advocating for One Health approaches in the blog, the point made is exactly that: to reinforce the need to transcend "purely" medical approaches, both conceptual and operational, since sustained interconnection with other sectors, including community involvement and mobilization coupled with communication strategies, do help prevent avoidable outbreaks of disease of animal origin whenever possible, detect threats early, and respond rapidly and effectively as shown under the Avian Influenza effort in countries such as Vietnam, Indonesia, and Turkey, or more recently with Bird Flu in China. And as you suggested, work at the community level is critical. I fully agree with it, but it should not be seen only for outbreak control and management, but for organizing and delivery health services as part of a care continium. Existing platforms such as Integrated Community Case Management (iCCM), do help to understand the context, inform and communicate, support social mobilization and involvement of the community, train and supervise health workers, adopt quality assurance measures, and increase access to treatment when required to those beyond the reach of health facilities. The challenge as I argued before, is how to institutionalize community based approaches to ensure that they are fully incorporated into national priorities, policies, and programs, with corresponding funding and capacities to sustain it. But once an outbreak occurs, medical countermeasures need to be adopted, including the prevention of "medical malpractices" that may contribute to the spread viruses or antimicrobial drug resistant organisms.

What are we doing to stop this being the "new normal"? Apparently not much!

Even China does not have public health systems to prevent disease outbreaks. This is the news today: an entire city has to be closed off because of plague. The economic damage is a thousand-fold or more of the death toll.

WHO Seeks Rapid Efforts Against Ebola: Addressing a meeting in Liberia, according to a press account, WHO's Regional Director for Africa, Dr. Luis Sambo, has called for accelerated efforts to control the deadly Ebola Virus Disease in the region. Dr Sambo stressed the need to step up implementation of key outbreak containment strategies, including community engagement and involvement, effective contact tracing, cross-border collaboration and effective coordination. He said: "The situation is quite serious and it should be addressed as an emergency."

Dr. Sambo also highlighted the need to strengthen social mobilization activities to raise awareness on Ebola within communities, as well as to enhance the protection of health workers, and to work with cross border collaboration.

Dr. Sambo reiterated WHO commitment to continue to work with the Government of Liberia and partners to mobilize adequate resources to address the Ebola epidemic, while commending health authorities for their efforts to control the outbreak. "I believe it is possible to stop the transmission and reduce the number of cases, but we still have a lot to do", he added.

You will find there detailed information about the WBG strategies and activities to support countries in dealing with this global risk. A severe pandemic would harm health, economies, and communities in all countries, but especially in poor and fragile states. Pandemic prevention requires robust public health systems (veterinary and human) that collaborate to stop contagion promptly.

WASHINGTON, August 4, 2014 – With the latest death toll from the West Africa Ebola epidemic now at 887, the World Bank Group today pledged as much as US $200 million in emergency funding to help Guinea, Liberia, and Sierra Leone contain the spread of Ebola infections, help their communities cope with the economic impact of the crisis, and improve public health systems throughout West Africa.

Just yesterday in Sierra Leone the Minister of Health confirmed that the country’s the lead medical doctor for Ebola and related diseases Sheikh Umar Khan has been tested positive for and is under treatment for the deadly disease. Same day, three nurses undergoing Ebola treatment died.
This has raised some valid questions:
1. If doctors, nurses and medical staff are themselves infected by Ebola - where should citizens now go for treatment when ill - even if their illnesses are not Ebola related?

2. Where are the Ebola deaths occurring most - is it at the hospitals/health centers or at homes? If the deaths are mostly in the hospitals and those included in the death toll are medical staff - is this really an incentive for people to go for treatment?

3. If there are so many untested and suspected Ebola victims running away from treatment, are they dying as much as those dying under treatment?

4. If not, are the prevailing citizens' suspicions against the high risks in treatment not justified?

5. Under what conditions are patients coercively put under high antibiotic treatment for Ebola? Hungry? Tired? Sick of other diseases ? Travelled ?

6. What are the names of the drugs administered on them and what are the contraindications and allergies associated with the treatment medications?

7. Are patients given oxygen masks when quarantined? How do they breathe inside the plastic sacs?

8. Is coercing Ebola suspects for treatment a better policy over persuading them with information about treatment benefits and risks?

Thanks for your comment. The situation in Sierra Leone is challenging as WHO has reported a total of 422 confirmed Ebola cases, and 143 people are known to have died from the disease. Efforts to strengthen the coordination of the response are being made, with the goal of having a concerted response across the Government. An Emergency Operations Center has now been established led by the Minister for Health and Sanitation. The UN agencies are also helping to develop a National Ebola Operational Plan and efforts are being made to mobilize donor support for priority needs.

Robust effort is required to support social mobilization and for contact tracing, as well as for clinical management of cases.

Based on various threads of debates on the Ebola crisis in Sierra Leone that I am personally following in the social media, the controversy in that country right now hinge on five communication based issues (i) perceptions about the accuracy of tests for Ebola, (ii) perceptions about the safety of treatment of Ebola, and (iii) coercion rather than persuasion of people suspected of Ebola to go for tests (by force), (iv) coercion rather than persuasion of people tested positive for Ebola to go for tests (by force), and (v) doubts and outright denial based on conspiracy theories. The international press is limitedly attributing the escalation of Ebola to only one of those causes – doubts/denial. What actually is reinforcing this fifth cause is the other four. Therefore public awareness should be heavy on messages about the ACCURACY of TESTS and SAFETY of TREATMENT. These two messages are what would give hope to people to flock to test and treatment places. The GUN cannot do it. So far the messages now reaching the public omit these two crucials. Talking about TESTS, one medical expert debating Ebola in the social media mentioned possibilities that the antibody tests being currently used to establish Ebola positives in Sierra Leone can sometimes show false results. On TREATMENTS - there is the problem of high fatalities. These two problems are repelling rather than attracting people to the "EbolaMedics. Even where public awareness is raised, the continuous infection and deaths of medical staff and low treatment survival rates among the affected population may not abate the controversy and unrest.

Thanks for your comment. The situation in Sierra Leone is challenging as WHO has reported a total of 422 confirmed Ebola cases, and 143 people are known to have died from the disease. Efforts to strengthen the coordination of the response are being made, with the goal of having a concerted response across the Government. An Emergency Operations Center has now been established led by the Minister for Health and Sanitation. The UN agencies are also helping to develop a National Ebola Operational Plan and efforts are being made to mobilize donor support for priority needs.

Robust effort is required to support social mobilization and for contact tracing, as well as for clinical management of cases.

Hi Patricio, Thanks for this post. The Ebola outbreak in West Africa does reinforce the importance of multi-sector engagement embedded in the One Health approach. Of course, it can be challenging enough to get the human health and domestic animal health experts collaborating. It is often much more difficult to facilitate communication between the health sector and agencies charged with addressing wildlife management or environmental planning. Outbreaks like the current one serve as important reminders that emergency planning exercises, routine communications, and confidence-building activities among the various health and environment actors at all levels are essential to anticipate problems and enable fruitful collaboration when emergencies do occur.

The outbreak – and the number of health care providers who have become infected -- also underscore the importance of making improved water, sanitation facilities, and hygiene materials available at all health care facilities – from the community clinic to the district hospital. All too often one hears that installation of WASH facilities is not the health institution’s responsibility or must be funded from a different pot of money. Governments and development partners can implement policies that all new health facilities built or supported must count on adequate WASH facilities, and they can develop a schedule to retrofit older ones, as well.

Thanks Katherine for your comments. Indeed, as you highlight, a whole-of-society approach is needed to prevent, detect and confront the onset of infectious diseases outbreaks which are inevitable. This, as in disaster preparedness, requires, as you suggest, ex-ante institutional measures and coordination arrangements supported by "confidence-building activities among the various health and environment actors at all levels" to "anticipate problems and enable fruitful collaboration when emergencies do occur."

Also, your point about the availability of safe water and basic sanitation services in health facilities is critical for effective outbreak management. But I would add that availability of these systems need to be complemented by efforts to promote the utilization of sanitation services and adoption of basic hygiene practices. This would help to modify risky behaviors such as open defecation or adopt hygine practices such as washing hands before and after seeing a patient.

What you say about prevention and preparedness, and how public health systems are needed, is very true. Not to be too cynical, it's also what people say during every crisis. Everyone sees the huge damage to people, communities and economies when a crisis is ongoing. So there is a blip of awareness that preparedness pays.

It's clear to all now that the crisis was caused by poor public health systems. The crisis did not have to happen. The crisis was preventable. This is all true.

It's also true that this is the case for this infectious disease outbreak crisis, as well as for the previous one, and the one before that. All of them could have been prevented by early detection and rapid containment of the outbreak. It's also known that governments chronically underinvest in public health, in capacities that detect disease outbreaks early and control them promptly. Nearly all World Bank public expenditure reports in the past 3 decades find that there is gross underspending on prevention. So this is not new knowledge, unfortunately for the poor who suffer the most from the setbacks of these crises. Unfortunately, nothing much happens as a result of this knowledge. "It's nobody's fault."

We know about the consequences of lack of preparedness and prevention, and we have known that before. Still, investments in public health (prevention of disease) are not on donors' lists of things to fund and promote. They are not on the government's list. So the investments are not made. This is a chronic situation.

I hope a bold journalist can interview the Ministers of Health who were in office 15, 10 and 5 years ago. Or perhaps a parliamentary commission can look into their records of spending on prevention and ask them why they did not prioritize public health, by financing functions where very small investments yield huge returns when an outbreak of Ebola or cholera or other such diseases starts and is promptly contained. Why did they not do much more to protect the population?

These are not unexpected events, they happen again and again. It's not plausible that the Health Ministers did not know. They did know that there is no accountability and perhaps also that the health ministry will get more money from donors during crises, certainly more than donors ever give for preparedness and prevention.

The first task of a health minister is to protect the public from contagion because only a government can do that. The economic rates of return on such investments are far, far higher than those on any other health ministry spending. The investments save lives, prevent misery of disease, protect communities and economies.

Without accountability and without vigorous advocacy for preparedness and prevention by partners who should know better, health ministers will continue to think too little about tomorrow, and the poor will continue to bear tragic and costly consequences of recurrent infectious disease crises.